An investigation into whether polypharmacy in hospice and palliative care patient population can be reduced, thereby affecting quality of life
Introduction
Polypharmacy simply refers to the use of several medications by patients. Sometime patients are prescribed several medications than what is clinically allowed or a patient may be given too many pills of drugs despite being clinically indicated. In addition, sometimes the drugs given to patients may not be evidence based but their use is only based on the speculations. Polypharmacy has been described to have a lot adverse effect on patients despite the patients being on medication. Instead of improving the quality of life, polypharmacy may sometimes prove to be adverse on patients. Common consequences of polypharmacy include negative drug reaction, high cost, and drug-drug interactions. This phenomenon of high usage of several medications by patients is common among elderly patients and patients under palliative or hospice care. The latter mainly involves patients with serious terminal illness such as cancer and HIV/AIDS.
This paper gives a reflective account and critique of literature review that enables an analysis of the use of polypharmacy on patients under palliative and hospice care. The primary focus of the analysis is to establish whether the phenomenon of polypharmacy can be reduced in order to improve quality of life in patients under palliative and hospice care. The review will include findings, results, and analysis of previous studies relating to the topic of interest in addition to incorporating results from a simple survey that was conducted. Main areas in this review include: a description of the problem of polypharmacy in palliative and hospice care, identification of the contributing factors, identification of barriers to discontinue multiple medication, and a description of recommendation to reduce polypharmacy in hospice and palliative care.
Bisht, et al. (2008) conducted a study that aimed at identifying symptoms at different stages of cancer development which are likely to be linked to the numerous numbers of drugs that they receive. In doing so, the article also sought to make recommendations that will rationalize the pharmacotherapy among patients in palliative care. According to the study patients under palliative care, especially cancer patients experience a large number of debilitating symptoms that result from the both the nature of their illnesses and also the brutality of the treatment they are subjected to. The symptoms are said to have adverse impact on prognosis, lower the quality of life, and increase the burden of morbidity. However, when the treatment of symptoms is improved, family and patient satisfaction is high as well as the quality of life. The article by Bisht, et al. (2008) therefore suggests the use of supportive care in treatment of cancer patients. The goal of palliation basically incorporates supportive care since it focuses on prevention, control and relief of side effects and other drug related complications. Palliative care seeks to improve quality of life and the comfort of patients however most patients under palliative care have to be predisposed to several drug related problems due to the fact that they are required to use several drugs in treatment of multiple symptoms.
The most common symptoms identified to be linked to polypharmacy among patients under palliative care included vomiting, nausea, fatigue, and pain. The findings were a confirmation of previous published studies that sought to examine the prevalent symptoms in cancer patients at the later or culminating stages of their lives. A common finding in many of the related studies is the adverse effect of polypharmacy. The patients are exposed to a lot of risks related to drug interactions. This therefore makes adherence to drug therapy a jeopardy instead of a way to improve quality of life among patients and their families.
Drugs used by hospice and palliative care patients with cancer were categorized into three main groups in the study by . The groups include: drugs for concomitant diseases, drugs used for treating and managing tumor related symptoms, and drugs for treating possible side effects. The study found out that many cancer patients are place under drugs for treating cancer related symptoms and drugs for treating and managing side effects. However, only 4 percent of the patients were placed under drugs for concomitant diseases. This therefore means that this category contributes insignificantly to pharmacotherapy . The classification of drugs was noted not to hold any ground when it comes to drugs that are used simultaneously with other drugs. For instance, a cancer patient can be given antiemetic to manage nausea before a session of chemotherapy. At the same time, a cancer patient can be given anti vomiting drugs before or after a session of chemotherapy. The study established that cancer patients are prone to develop ulceration in the stomach or gastritis firstly because of psychological stress and secondly because of using anti inflammatory drugs and chemotherapeutic agents . In other cases, drugs are simply prescribed on to patients majorly because of the placebo effect. This supports the statement that some of the drugs used by patients under hospice and palliative care are not evidence based however their use only creates a placebo effect. The study also concurs with that of .
Griffith, et al. (2002) says that there have been numerous benefits experienced by patients through judicious and appropriate use of drugs. However, the study also notes that polypharmacy has the potential to cause problems in patients. It is in the care of the elderly and patients under palliative and hospice care that the harmful effect of using several drugs at once is witnessed. As people grow old the chances of them suffering from numerous health conditions increase. Similarly, patients suffering from serious illnesses and terminal diseases have increased chances of developing other conditions. This therefore requires the two groups to benefit from the drugs that control and manage all these conditions. But one thing that has raised serious concerns is the negative effect of the patients using several drugs at once. This causes an emergence of side effects that which affect important and critical body functioning. For instance, there can be changes in metabolism and increased effect of drug interaction. In as much as the polypharmacy is associated with reduced compliance to pharmaceutical treatments, the phenomenon is also associated with adverse drug reactions. The article therefore suggests that the best way to handle the situation is to evaluate the potential benefits associated with polypharmacy and weigh them against the risk involved. This will provide a strong basis upon which decisions and policies can be based. There is also need for more research to be done to establish the evidence for the effectiveness and harmful effect of polypharmacy.
The findings of have been confirmed by . say that polypharmacy is common in elderly patients because they have increased chances of having multiple morbidities. Since elderly patients generally have a decline in their physiology, it is possible for the drugs to have adverse reaction when several are used at the same time. The case is similar for patients under hospice and palliative care because their bodies suffer a reduced immunity. Multiple adverse symptoms and drug interactions are among the other consequences of polypharmacy identified by .
Koh and Koo (2002) say that it is important to reduce polypharmacy. In their study, Koh and Koo (2002) sought to examine whether it is possible to reduce the use of several drugs on patients under palliative and hospice care. The study was done by looking at the medication charts of the participants. A total of 345 patients were selected for the trial. The drugs used were recorded before and after referral. The study noted that reducing the use of several drugs by patients under palliative and hospice care is not that simple. It is in fact often difficult to reduce polypharmacy because the drugs used in the treatment and management of terminal illnesses tend to rely on additional supplements in order to be effective on the body. However, in order to minimize polipharmacy, patient education and reviewing the use of some drugs is important.
Contributing factors to polypharmacy
Colley & Lucas (1993) note that polypharmacy occurs when there is at least one useless or unnecessary medication in a medical regimen. The authors also note that polypharmacy is indeed a problem. The factors identified to contribute to the problem can be classified into two main categories: patient factors and physician factors. Patient factors result from the activities and general characteristics of the patients while physician factors result from the personal and professional decisions made by physicians. Some of the patient factors may include old age, decision to self treat, therapy expectation, and multiple medical problems. Some of the physician factors may include a lack of coordinating providers, multiple providers, and excessive prescription. Colley & Lucas (1993) suggest that in order to simplify medication regimen, there is need to avoid pharmacologic duplication. Additionally, they also suggest the need to regularly review medical regimen and decrease dosing frequency among patients. While prescribing drug regimen for hospice patients, there is need to consider cost of therapy, medical symptoms, and medical problems.
Stockpiling of medication has also been identified as one of the contributing factors. Stockpiling normally occurs as a result of the high cost of medication. Patients would keep stock of pills for future use and sometimes the drugs may not be useful when used in the future.
Since polypharmacy has the potential to duplicate the actions of other drugs and to encompass inaccurate dosage, reducing polypharmacy therefore becomes necessary. Patients in hospice and palliative care are often make complaints about chronic illnesses and it is common for care providers to continue prescribing drugs to address every complaint. In addition, the patients always complain about the side effects of the drugs and in the same way it is common for the care providers to prescribe more medication and supplements to address the side effects. This is primarily where polypharmacy begins. In a similar manner as elderly patients, terminally ill patients may sometimes be required to consult numerous specialists because of the development of multi symptoms and the complexity of the illnesses. The specialist end up prescribing drugs with complete disregards of the other drugs that the patients may be using. Herbal drugs are also common among the patients. Herbal drugs are especially taken with little consultation from a care provider. The substances therefore can interact with the prescribed pharmaceutical drugs leading to adverse reactions and other harmful effect on patients.
Preventing polypharmacy can help in various ways including decreasing toxicity of medication, inappropriate dispensation of drugs, duplication of drugs, incidences of adverse medication events, hospitalization due to drug interaction, and high cost of care.
Results from interview with hospice care providers
In order to develop a reflective analysis of the topic under consideration, interviews with three medical professionals in the palliative and hospice care were conducted. The first interview was with Dr Kristin Keefe the Hospice Medical Director for McCarthy Care Center in East Sandwich Ma., USA. During the interview, Dr Kristin managed to provide insight in the issue from the perspective of a care giver. With regards to the view on polypharmacy as it relates to the Hospice and palliative Care population, Dr Kristin said that polypharmacy is a significant problem in the hospice and palliative care patient population. Many symptoms occur as a result of inattention to medications. These assertions were in accordance with many of the literature materials earlier reviewed in the paper.
In regards to his opinion about the need to do something about polypharmacy in patients under hospice care, he was very categorical to say that indeed something has to be done as polypharmacy has been proven not to improve the quality of life. He added that physicians, be they primary care physicians or consulting physicians, need to speak to each other about their patients so that they each know which medications they have put patients on and for what reasons. Also, when a patient is admitted to a palliative care service or a Hospice service, the hospice medical director and or nurse practitioner should be speaking to the primary care physician informing them of the change and the reason for admission to the particular service and at that time conducting a medication review.
Physicians and hospice medical care providers have a role to play in attempting to decrease polypharmacy in patients. Dr. Keefe was keen to note that at the McCarthy medical center, physicians and care providers need to discuss in order to improve their role into the situation. According to Dr. Keefe, A simple discussion at the start of care or transfer to McCarthy Care Center to profile and reconcile medications would be of tremendous help. It could act as a starting point to identify drug to drug interactions and any unnecessary medications a patient may be taking.
Dr Keefe also talked about the factors that lead to polypharmacy in hospice and palliative care. In a one statement respond, he concurred with the assertions of the numerous studies discussed. He said that here are too many people involved and then actually no one person ends up being in charge as well as a lack of education in end of life care. He also noted that there is a lack of safety, including increased falls, as well as other adverse events such as hypoglycemic episodes, hypotension, constipation and delirium. These, according to him are some of the negative effects of polypharmacy.
With regards to barriers contributing to the ability to reduce polypharmacy, Keefe responded by saying that the barriers include that there is no one person who is accountable, the RN Case Manager in the home is not reviewing medications at each home visit as there is so much to be done in caring for the patient so the medications are not scrutinized as they should be.
Lastly, his opinion regarding elements that could be instituted to reduce polypharmacy was that there should be a set process that requires sign off by the primary care Doctor and the Nurse Practitioner and or Medical Director from Hospice that are caring for the patient within the first twenty four hours of admission to McCarthy Care Center. This would also double as good PR for us to be in touch with them about their patient.
In a different interview, the researcher sought the opinion of Michael Torosian, a client relation liaison at the Omnicare Company. a summary of the interview findings is provided below:
What are your views on polypharmacy as it relates to the Hospice and Palliative Care patient population? Overall, the elderly receive about 40% of all prescribed medications. About 80% of all hospice patients fall into the elderly category. This is clearly an area of concern due to multiple conditions that come along with advanced age, as well as the use of multiple prescribers. Not only does it increase the risk of adverse drug reactions, but it can contribute to poor medication adherence and unnecessary medication expenses.
In your opinion, can something be done to reduce polypharmacy in this patient population? Absolutely, medication reviews need to be more thorough upon patient admission. It is important to ask questions and involve other healthcare professionals when reviewing the patient’s medication regimen. Medications should have a clear indication and duplicate therapy can easily be identified.
What could be a specific role for the Medical Director and Hospice Pharmacist in an attempt to decrease polypharmacy in the patients at McCarthy Care Center? Get a pharmacist involved early on to identify medications that may not be necessary. Addressing this sooner than later is extremely important. Set hospice specific protocols where necessary/appropriate so everyone is on the same page. This needs to be a collaborative effort. Review charts regularly. Identify what is related vs. not related to the patient’s diagnosis. Each medication should have an indication and the patient should know why they are taking it.
Specific Questions:
What are the important factors contributing to polypharmacy in Hospice and Palliative Care? Multiple prescribers, multiple disease states, age, lack of recognition of side effects (using more drugs to treat a side effect of another drug)
What are some of the negative effects of polypharmacy? Increased risk of adverse drug reactions, increased medication expenses, decreased medication adherence
Are their specific barriers that contribute to the ability to reduce polypharmacy? Patients/caregivers may be reluctant to discontinue certain medications – fear of abandonment, clinician fear of damaging patient relationship by removing certain medications, physiological dependence
Are their specific elements that could be instituted to reduce polypharmacy? (Education, Interventions etc.) Education – being able to identify and prioritize, communication with other healthcare professionals is critical. It is important to monitor patients for beneficial or harmful effects. Stick to more simple regimens when possible
Conclusion
It can be argued that it is not that simple to completely eliminate the polypharmacy. There are factors that lead to the phenomenon as well as barriers that prevent a reduction of using multiple medications. The factors identified to contribute to the problem can be classified into two main categories: patient factors and physician factors. Patient factors result from the activities and general characteristics of the patients while physician factors result from the personal and professional decisions made by physicians. Some of the patient factors may include old age, decision to self treat, therapy expectation, and multiple medical problems. Some of the physician factors may include a lack of coordinating providers, multiple providers, and excessive prescription. These findings were confirmed in the three interviews conducted with hospice care providers. For instance Dr. Keefe says that here are too many people involved and then actually no one person ends up being in charge as well as a lack of education in end of life care.
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